IUD Access Program Application

Desert Star Institute for Family Planning, Inc., understands that sometimes people face financial challenges, and we are here to help. We have partnered with Direct Relief, a charitable organization, to provide Liletta® intrauterine devices to qualified patients.
  • Our program assistant will contact you to review your application and determine your eligibility.
  • Date Format: MM slash DD slash YYYY
  • Please provide the number for each column of adults and minors in the first columns and the total in the last column.
    Number of Adults in HouseholdNumber o Minor Children/DependentsTotal Number in household 
  • Do you have health insurance?

  • Please list your MONTHLY gross household income (Income before taxes or deductions) calculated for all household members Age 19 or older

  • Pay, Wages, or SalariesTipsUnemployment benefits 
  • Social Security BenefitsPublic Assistance Benefits (TANF)Disability, workers compensation, or other payment for an injury or illness 
  • Retirement or pension benefitsAlimony or child support paymentsInsurance or annuity payments to me 
  • Interest or dividends from savings accounts or investments or any withdrawals from these accountsRental income or other income from a BusinessIncome from royalties, patents, gambling, or lottery winnings 
  • Patient Attestation:

    I attest that all the information that I have provided to determine my eligibility for this product donation program is complete and correct to the best of my knowledge. I understand that I cannot request reimbursement for any prescription product received through this program from any government program or third-party insurer. I further agree to notify the clinic of any changes in my income or insurance, or other factors used to determine my eligibility status were I to receive donated product in the future. I authorize the release of my Protected Health Information (PHI) for this patient assistance program or any third parties retained to administer the program and who may audit my PHI for the purpose of verifying my eligibility.
  • Date Format: MM slash DD slash YYYY